- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.00 / $1,300.00 / $3,500.00
| Facility | | $338.00 | $1,300.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.83 / $315.83 / $315.83
| Professional | | $315.83 | $315.83 | $315.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.17 / $4,321.93 / $9,173.53
| Facility | | $2,116.17 | $4,321.93 | $9,173.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $10,810.00
| Facility | | $1,141.00 | $4,717.00 | $10,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.31 / $268.58 / $491.21
| Professional | | $184.31 | $268.58 | $491.21 |